GW1-2021-00162_Well Construction - GW1_20211213

WLIJL UUMIRUU11ON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM R TZ ONE DESCPEMON-
Well Contractor Name ftJq
ft
NCWC 2028-A ft 3-7 it
NC Well Contractor Certification Number 15:OUTER CASING at mal6-c�sed.wdls ORL MR C,f bie
FROM TO DIAMETER nUCSNM I MATERIAL
Ferguson's Well and Pump, LLC fc ft j
Company Name 16.•INNER CASING OR TUBING. dosed
FROM TO DIAMETER TEIICKNES4 MATERIAL
2.Well Construction Permit#: (I)e-11- `;2 oa ( - 005 S ft. TO
;R
List all applicable well construction pennits(i.e.Cow*,'Sia?e,Aariance,etc.)
ft ft in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM I TO DIAMETER SLAT SSM I TffiCKNFSS I MATERIAL
ft in.
❑Agricultural ❑ ipaUPublic
❑Geothermal(Heating/Cooling Supply) laResidenbal Water Supply(single) E�Eft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 11L GROUT
FROM TO MATERIAL EMPLACEMZNT METHOD&AMOUNT
❑iti ation . 0 ft20 Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Reccovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANiD/GRAVEL PACh►. e
❑Aquifer Storage and Recovery ❑Salinity Battier FROM ft TO I MATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage h ft
❑Experimental Technology ❑Subsidence Control
X DR111 ING LOG.attar°additibW sbeets if
❑Geuthermal(Clusud Luup) ❑Traver FROM TO DESCIilY1TUN color bards solUroclt 0ei grWo d2e,etc
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) ft ft tvu
f4 eft
4.Date Well(s)Completed: Well 1D# ft ft
Sa.Well Location:
fad
ft ft a
Ic
Ic ty i s i tley_S 04 ik ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft 'd > r >
1' I'((� j `a lk r
ILA bliV61i TjjtAet 01c �iGT�nCI� a8'73 a` ft ft -
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and Longitude to degrees/udiintedseconds or decimal degrees: 22 CertiScation• t'
(if well field,one lat/long is sufficient) .
S" 34 r�N •d�.S�a4, 3/�1/`r W A&
Signature of "fled e11 Con for
6.Is(are)the well(s): a .ment or ❑Temporary
By signing dds farm,I Ii-&certify that the well(s)was(were)eonsurrcted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl ConstrictionStandhn*and that a
7.Is this a repair to an existing well: ❑Yes or B1Vo copy of this record has been provubd to the well owner.
If this is a repair,fill otd known well construction i 1formatm and explain the natw+e of&
repair raider#21 rrmarb section or on die back of tW form. 23.Site diagram or additional well details:
You may use the back of this page�to provide additional well site details or well
S.Number of wells constructed: % construction details. You may also attach additional pages if necessary.
Formuitiple bgection or icon-water supply wells O Y wfth de same cartsQrudiort,you vain
submit oneforra ,+ SUBM1TfAL INSTUCTIONS
9.Total well depth below land surface: (g•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d f—t(exmnple-3@20W and 2@100 construction to the following:
10.Static water level below top of casing: 00 Division of Water Quality,Information Processing Unit,
#'water level is above casing,use"+" 1617 Mal Service C�nter,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 241b.For X1 eetiou Wells: In addition to sending the form to the address m 24a
Rota above, also submit a copy of this him within 30 days of co>pletion of well
12-Well conamcdon method: ry construction to the folluuing: w
(i.e.auger,rotary,cable,direct push,etc.) �'
Division of Water Quality,Unidergrotmd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24e.For Water Supnly&Inicetiou Wells: In addition to sending the form to
� the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: OZ• completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013